Antibiotic Stewardship Programme (ASP) in hospitals: current practice and challenges
KW Choi Regional Symposium on AMR 13 November 2018
Chronicle
What and how we are doing now
Day 1: Appropriate indication(s)
Day 3 - 4: De-escalation
IV to PO switch
Day 5 - 7: Stop antibiotics
early
4
Biomarkers: procalcitonin
Known pathogen therapy when Ix results a/v
Guidelines Education / training Microbiological Ix Rapid diagnostics
Ongoing clinical assessment
Opportunities for ASP interventions
(2) Prescribe antibiotics according to IMPACT
Laboratory (1) Perform tests
ASP Team
Clinicians
(1) Order microbiological investigations
(2) Report Ix results
(3) Ongoing review of clinical response and Ix result
Audit the case / review the appropriateness of antibiotic use
(1) Concurrent feedback (2) Issue audit report • Appropriateness of
empirical use of antibiotics
• % of compliance to concurrent feedback
• Antibiotic consumption data
Clinical Depts (ICU, Med, Surg, Orth) (4) Performance
improvement based on audit report
Day 1 … … Day 4 … … Day 7 … … Quarterly
X
5
PCT if indicated
Targeted antimicrobials for interventions
• Imipenem/ meropenem, piperacillin-tazobactam (surrogate markers for “big gun” antimicrobials; represents > 70% of consumption): review +/- concurrent feedback as appropriate
• ASP team to review all “last resort” antimicrobials prescriptions (e.g. colistin)
• Workgroup on ASP to give recommendations on indications of new and reserved antimicrobials for multi-drug resistant organisms
Acute DDD/1000 acute BDO – By Group
Group 1 Cefepime Ceftazidime Meropenem Tazocin Cefoperazone-sulbactam Imipenem
Group 2 Ticarcillin-clavulanate Piperacillin Cefotaxime Ceftriaxone
Group 3 Vancomycin Linezolid
Group 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018Q1 2018Q2 2018Q308 vs.
baseline 18Q3 vs. 08Trend
05 to 08Trend
08 to 18Q318Q3 vs.baseline
Group 1 -Big Gun 38.95 37.43 37.52 36.00 41.52 38.41 38.56 46.89 56.90 67.31 80.96 87.53 93.74 99.72 98.00 103.2 -8% 187% 165%
IV FQ 10.35 9.36 8.61 7.59 8.25 8.01 6.97 7.76 7.63 9.16 9.50 9.59 9.31 8.25 9.57 10.25 -27% 35% -1%
Group 2 17.19 18.16 22.06 23.53 25.15 32.02 32.04 33.52 33.16 32.24 28.24 30.35 30.17 32.06 28.47 29.92 37% 27% 74%
Group 3 7.05 7.51 7.66 7.29 8.35 8.95 10.33 10.78 12.05 13.51 15.03 16.22 16.95 16.91 17.59 18.77 3% 157% 166%
Allantibiotics 740.0 738.8 766.3 770.0 794.4 841.5 814.6 850.1 856.7 874.3 890.0 904.4 899.9 950.7 888.5 903.4 4% 17% 22%
Linezolid, Colistin, Ertapenem, Tigecycline, Daptomycin, Ceftaroline: acute DDD/1000 acute BDO
Group 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018Q1 2018Q2 2018Q308 vs.
baseline 18Q3 vs. 08Trend
05 to 08Trend
08 to 18Q318Q3 vs.baseline
Linezolid 0.47 0.50 0.41 0.32 0.68 0.66 0.78 1.03 1.23 1.65 1.53 1.51 1.58 1.89 1.61 1.39 -32% 335% 196%
Colistin 0.07 0.05 0.03 0.12 0.40 0.55 0.60 1.01 1.69 2.90 2.84 2.28 2.10 1.89 1.78 1.76 71% 1364% 2409%
Ertapenem 0.00 0.15 0.62 0.90 1.80 3.14 3.47 4.23 4.59 4.48 4.47 4.72 4.76 5.01 5.52 5.86 - 551% -
Tigecycline 0.00 0.03 0.13 0.24 0.31 0.21 0.21 0.20 0.30 0.33 0.42 0.43 0.44 0.37 0.48 0.45 - 88% -
Daptomycin 0.00 0.00 0.00 0.03 0.07 0.14 0.18 0.40 0.53 0.58 0.87 1.05 1.38 1.38 1.30 1.26 - 4114% -
Ceftaroline NA NA NA NA NA NA NA NA NA NA NA NA NA 0.42 0.42 0.30 - - -
Allantibiotics 740.0 738.8 766.3 770.0 794.4 841.5 814.6 850.1 856.7 874.3 890.0 904.4 899.9 950.7 888.5 903.4 4% 17% 22%
Outcome markers
1. Antibiotic consumption data DDD per 1000 acute patient bed days
2. Percentage of appropriate use of empirical antibiotics
3. Percentage of compliance to concurrent feedback
Key points for prescribers
1. Appropriate clinical specimens for microbiological investigations before starting Rx
2. Choice & dose according to guidelines
3. Oral/ step-down Rx
4. Limit Rx duration
Gaps and challenges
ASP Team • Increasing diversity, complexity and
volume of workload • Growth of workforce not matched with
service demand Limited resource for implementation of ASP
Budget holders • Shortage in manpower (doctors,
nurses,…) • Other competing interests within
healthcare sectors • Effects of ASP not directly tangible Implication on resource allocation
Frontline doctors • Aging population, multiple co-morbid and
chronic illnesses, expanding population of immunocompromised patients
• Prevalence of MDRO on the rise Pressing need of broad spectrum antimicrobials for treatment (both empirical and pathogen specific)
Impact on sustainability of ASP
Looking forward: application of information technology
In-patient medication order entry (IPMOE) • A function of the Clinical Management System (CMS) • An electronic platform for prescription of drugs for in-patients • Enrolled in phases to all HA hospitals
Assist with dosing & Using common orders and standard regimen
Common Orders
Stop order reminders or flags – Drug Review
Possible future development of IPMOE
• Standard list of indications for
targeted antimicrobials
• Tracking of antibiotic
prescription history
• Link to guidelines
• Dose calculators
Our long term goal: decision support system on
antimicrobial prescribing